Rheumatoid Arthritis and the Cervical Spine: A Review on the Role of Surgery.

Gillick JL, Wainwright J, Das K - Int J Rheumatol (2015)

Bottom Line:
Cervical spine involvement in RA can pose a challenge to the clinician and the appropriate role of surgical intervention is controversial.With the advent of disease modifying antirheumatic drugs (DMARDs), fewer patients are presenting with cervical spine manifestations of RA; however, those that do, now have improved surgical techniques available to them.We hope that, by reading this paper, the clinician is able to better evaluate patients with RA in the cervical spine and determine in which patients surgery is indicated.

ABSTRACTRheumatoid arthritis (RA) is a chronic systemic inflammatory disease affecting a significant percentage of the population. The cervical spine is often affected in this disease and can present in the form of atlantoaxial instability (AAI), cranial settling (CS), or subaxial subluxation (SAS). Patients may present with symptoms and disability secondary to these entities but may also be neurologically intact. Cervical spine involvement in RA can pose a challenge to the clinician and the appropriate role of surgical intervention is controversial. The aim of this paper is to describe the pathology, pathophysiology, clinical manifestations, and diagnostic evaluation of rheumatoid arthritis in the cervical spine in order to provide a better understanding of the indications and options for surgery. Both the medical and surgical treatment options for RA have improved, so has the prognosis of the cervical spine disease. With the advent of disease modifying antirheumatic drugs (DMARDs), fewer patients are presenting with cervical spine manifestations of RA; however, those that do, now have improved surgical techniques available to them. We hope that, by reading this paper, the clinician is able to better evaluate patients with RA in the cervical spine and determine in which patients surgery is indicated.

fig3: Lateral radiograph of patient with severe cranial settling. Of note, the settling is so severe that the dens is not identifiable due to overlying mastoid air cells and skull base, arrow identifying the anterior arch of C1 (a). Sagittal reconstructions of computed tomography of the cervical spine in the same patient. Note the anterior arch of C1 is at Station III and the dens (arrow) projects through the inferior margin (line) of the foramen magnum (b).

Mentions:
There have been numerous measures proposed to evaluate radiographs for the presence and severity of CS; however these approaches have proven to be difficult to reproduce and as disease progresses, difficulty in visualizing landmarks complicates their use (Figure 3) [1, 2, 7, 36]. Based on the work by Riew et al., the presence of CS is best evaluated using a combination of the Clark station, Ranawat criterion, and the Redlund-Johnell criterion (Table 3) (Figures 4, 5, and 6). When at least one of these measures is positive, the sensitivity for detecting CS is 94% with a negative predictive value of 91%. However, this combination only has a positive predictive value of 56% meaning a large number of patients would be diagnosed as potentially having CS in the absence of disease and therefore magnetic resonance imaging (MRI) or computed tomography (CT) is recommended [36]. When considering the high morbidity associated with CS, this high false-positive rate may be considered acceptable.

fig3: Lateral radiograph of patient with severe cranial settling. Of note, the settling is so severe that the dens is not identifiable due to overlying mastoid air cells and skull base, arrow identifying the anterior arch of C1 (a). Sagittal reconstructions of computed tomography of the cervical spine in the same patient. Note the anterior arch of C1 is at Station III and the dens (arrow) projects through the inferior margin (line) of the foramen magnum (b).

Mentions:
There have been numerous measures proposed to evaluate radiographs for the presence and severity of CS; however these approaches have proven to be difficult to reproduce and as disease progresses, difficulty in visualizing landmarks complicates their use (Figure 3) [1, 2, 7, 36]. Based on the work by Riew et al., the presence of CS is best evaluated using a combination of the Clark station, Ranawat criterion, and the Redlund-Johnell criterion (Table 3) (Figures 4, 5, and 6). When at least one of these measures is positive, the sensitivity for detecting CS is 94% with a negative predictive value of 91%. However, this combination only has a positive predictive value of 56% meaning a large number of patients would be diagnosed as potentially having CS in the absence of disease and therefore magnetic resonance imaging (MRI) or computed tomography (CT) is recommended [36]. When considering the high morbidity associated with CS, this high false-positive rate may be considered acceptable.

Bottom Line:
Cervical spine involvement in RA can pose a challenge to the clinician and the appropriate role of surgical intervention is controversial.With the advent of disease modifying antirheumatic drugs (DMARDs), fewer patients are presenting with cervical spine manifestations of RA; however, those that do, now have improved surgical techniques available to them.We hope that, by reading this paper, the clinician is able to better evaluate patients with RA in the cervical spine and determine in which patients surgery is indicated.

ABSTRACTRheumatoid arthritis (RA) is a chronic systemic inflammatory disease affecting a significant percentage of the population. The cervical spine is often affected in this disease and can present in the form of atlantoaxial instability (AAI), cranial settling (CS), or subaxial subluxation (SAS). Patients may present with symptoms and disability secondary to these entities but may also be neurologically intact. Cervical spine involvement in RA can pose a challenge to the clinician and the appropriate role of surgical intervention is controversial. The aim of this paper is to describe the pathology, pathophysiology, clinical manifestations, and diagnostic evaluation of rheumatoid arthritis in the cervical spine in order to provide a better understanding of the indications and options for surgery. Both the medical and surgical treatment options for RA have improved, so has the prognosis of the cervical spine disease. With the advent of disease modifying antirheumatic drugs (DMARDs), fewer patients are presenting with cervical spine manifestations of RA; however, those that do, now have improved surgical techniques available to them. We hope that, by reading this paper, the clinician is able to better evaluate patients with RA in the cervical spine and determine in which patients surgery is indicated.